Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /ce,17a4 FA000006 52o�7�t�1 <br /> OWNER/OPERATOR CHECKlf BILLING ADDRESS❑ <br /> FACILITY NAME / I�c.� O^ / • I©S J ` T 1 <br /> SITE ADDRESS // /O / W K— ®V �Ql•(� 7t/-�.Ll �--D Gr l� y.Sa qL <br /> Sheet Number Direction Street Name CIS/ zi Ceae <br /> HOME Or MAILING ADDRESS (If Different from Site Address) //2?✓. /����uµyK� /L Ie�G�f 7j>r r'�•� <br /> street Number Street Name <br /> CITY �Q j STATE CA <br /> ZIP <br /> PHONE#1 6 EXT. APN# PLANO USE APPLICATION#(0 71 — I D(,� � �2pL-(�5 <br /> PHONE#2T• S DISTRICT LOCATION CODE <br /> ( ) ©7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /4' III <br /> - <br /> ( ne rf(/� CHECK If AiLuNG ADDRESS <br /> BUSINESS NAME ??^ �I .�Q. �� �.5 LLC (,t)c �'QRL NE <br /> �5j,,, P O 6 <br /> Ir <br /> HOME Or MAILING ADDRESS FAX# <br /> `{33 rlolce/u�� (l�✓vim D���� c ) / <br /> CITY LOQ/ STATE j ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa::ZZMQ� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERIA OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof Of authorization to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me Or <br /> my representative. f <br /> TYPE OF SERVICE REQUESTED: f -WJ PVI.L I ►riENT <br /> C;, <br /> COMMENTS: / 9 (' RECEIVE <br /> 6 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: .1.O rG1` EMPLOYEE M ATE: <br /> ASSIGNED TO: RAr1il EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (96 1 PIE: 160-1 <br /> Fee Amount: 5� �,� Amount Paid I S Payment Date 3 ,6 . <br /> Payment Type Invoice# Check# --- Received By: <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S Cav\ <br />